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Value guided healthcare as a platform for industrial
development in Sweden – feasibility study
Final Documentation
August 28, 2009
Project context – Background
Sweden has historically had a very strong reputation for it's clinical research. Its importance for the country
through contribution to a productive health care system as well as the development of both major BioPharma
and MedTech companies is uncontested.
Over the past years several investigators have documented that Sweden's position in clinical research is
deteriorating. The reasons are many and several excellent suggestions on how to address the situation have
been proposed.
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
In 2008 a leading Swedish industrialist Carl Bennet gathered the 50 most senior leaders from
Payers/providers, from Academia and Industry to discuss the situation and propose actions to Government.
Aug 18 2009 the same group was invited to discuss a concrete proposal and plan for action. In preparation a
BCG team was commissioned to assess the potential importance of Sweden's quality and patient registries.
The team formulated a 10 year vision, translated this into a concrete governance model and a 10 year
implementation plan. The project was jointly sponsored by AstraZeneca and Carl Bennet AB and executed
during 10 weeks May-July, 2009
A central insight in the project is that Health care in the Western countries needs transformational change in
order to improve productivity and secure that the broader population can get access to high quality care and
innovation. This transformation will not be successful if the motivation for clinical staff is efficiency and cost
containment. In order to mobilize the base of the pyramid in the transformational efforts the focus has to be
the quality of care for the patients.
Value guided healthcare_Final Documentation_Aug09.ppt
1
Project context – Objectives
Define a 10-year vision for how Sweden could take a leading position internationally in
value based healthcare
Define Sweden's current position in an international context, key strengths and barriers
to change
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Propose strategic priorities and estimate business case
Describe key actions, timeline and stakeholder actions required to deliver on strategy
Engage key stakeholders to test support and secure well founded recommendations
Value guided healthcare_Final Documentation_Aug09.ppt
2
Executive summary
Providing high quality healthcare at reasonable cost is one of the most pressing issues facing
industrialized countries today
• Unsustainable growth in spend across countries, exacerbated by current downturn
• Sweden with additional challenge from drop in clinical research and healthcare industry activity
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Emerging health care "value paradigm" will increase industry productivity by focusing on outcomes/cost
• Cost-focus needs to be coupled with focus on outcomes to secure strong engagement by practicing
clinicians in the required industry transformation
• Sweden with ~5 year head-start in new paradigm due to unique quality and patient registries
With shared vision and a coherent national strategy, Sweden could build world-leading platform in valuebased healthcare within 10 years
• Positive and strong incentives to develop effective care for patients through transparency on performance
• Increasing clinical demand for innovation to improve care performance will enhance "translational" links
between basic research and clinical practice
• Platform for industry to develop and test products meeting market requirements for healthcare productivity
and safety
Swift action needed to leverage ~5 year window of opportunity
• Leadership by state and counties to define national strategy and provide seed financing
• Participation of all key stakeholders in defining policies, executing the strategy and realizing the vision
• Build national platform for quality registries while maintaining strong sense of ownership among clinicians
Value guided healthcare_Final Documentation_Aug09.ppt
3
Current study scope holistic – integrating efforts by many
Many stakeholders,
initiatives, projects...
...but all agree coordinated efforts are lacking
"We see huge potential and we are realizing
some, but we lack a joint vision to work towards"
"We have seen definite cases of 'turf wars' "
Scope of study
to bring efforts together towards
common vision and roadmap
Concrete and realistic 10-year vision with
healthcare system perspective
• Ambitious but tried and tested
• Anchored in international outlook
Current landscape, vision and roadmap
discussed with all key stakeholders
• >70 interviews
• Proposal built on strengths of current model
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Large interest in outcomes but
lack of shared vision, clear leadership
and coordination
Roadmap allowing for paced implementation
• Interdependencies few but important
• Providers and other stakeholders can
contribute independently
"We're afraid all these uncoordinated efforts can
cause fatigue and make us lose momentum"
System perspective outlines one of the most attractive
future industry platforms for Sweden
Source: Stakeholder interviews April – June 2009, BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
4
Preface
This material contains copies of slides prepared by members of The Boston Consulting
Group, Inc, for the seminar "Sweden as the international leader in outcome based
healthcare", held in Gothenburg August 18th, 2009. A list of all the participants at the seminar
can be found in Appendix.
The slides are incomplete without accompanying oral commentary
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
The market and business case estimates contained in this presentation are based upon
standard methodologies using public data, market interviews and assumptions derived from
the insight gained during the project and data entrusted to The Boston Consulting Group
(BCG). BCG has not independently verified all of the data and assumptions used in these
analyses. Changes in the underlying data or operating assumptions will clearly impact the
analyses and conclusions
5
Agenda
Starting position
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Shared vision and value captured
Way forward
Appendix
Value guided healthcare_Final Documentation_Aug09.ppt
6
Unsustainable growth in healthcare spend
Per capita HC exp 2006
€2,650
Per capita HC cost 2006
€2,250
Index
(1992=100)
300
Per capita HC cost 2006
€1,850
Index
(1992=100)
300
HC Cost
300
GDP
HC Exp
GDP
200
100
1992
Wages1
1995
Index
(1992=100)
1998
2001
2004
2007
HC Cost
200
100
1992
Wages1
1995
1998
Index
(1992=100)
Per capita HC cost 2006
€3,150
300
200
Wages1
GDP
2001
2004
2007
100
1992
1995
1998
Index
(1992=100)
Per capita HC cost 2006
€ 5,351
300
2001
2004
Per capita HC cost 2006
€3,150
300
HC Cost
HC Cost
200
GDP
GDP
200
1995
1998
2001
2004
2007
HC costs
200
GDP
Wages1
Wages1
100
1992
100
1992
2007
1995
1998
2001
2004
2007
Wages1
100
1992
1995
1998
2001
2004
2007
1. Average nominal wage index
Note: Index on basis of local currency; Per capita HC cost 2006 at exchange rate of 1 USD=0,797 €, 2005: 110,22 Yen/US$
Source: OECD Health Data 2008; EIU
Value guided healthcare_Final Documentation_Aug09.ppt
7
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Index
(1992=100)
Sweden's strength in healthcare increasingly challenged
Sweden losing clinical
trial volumes
Medically trained students
shrinking share of
Medical faculty PhDs
Drop in
registered patents
Ongoing clinical trials
per year in Sweden (#)
Patents registered
at PRV (#)
600
400
# PhD students
at medical faculties1
CAGR
6,000
~-25%
+4%
300
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
4,000
400
200
-1%
2,000
200
100
0
0
0
Average 95-97
Average 04-08
00
01
02
03
04
05
06
07
08
90
92
94
96
98
00
02
04
06
Industrial chemistry
PhD Students at medical faculties, total
Organic chemistry
PhD students at medical faculties with MD
Biotechnology
1. At Uppsala University, Karolinska Instritutet; Lund University and Gothenburg University
Note: CAGR=Compounded Annual Growth Rate
Source: Klinisk forskning – ett lyft för sjukvården, Läkemedelsverket; SCB; Teknikområdesbarometern 2006-2008 PRV; BCG Analysis
Value guided healthcare_Final Documentation_Aug09.ppt
8
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Improving healthcare easier said than done
Source: The Economist
Value guided healthcare_Final Documentation_Aug09.ppt
9
Value based healthcare new paradigm emerging
1980
1990
2000
2010
Efficacy and safety
Scientists
Administrators
Efficiency
Clinicians
Outcome metrics, eg;
• Mortality
• Mobility
• Pain sensation
• Activities in daily life
• Post-op infection
Outcome
Cost
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Pre-1980
Value
• Measured as outcomes, not inputs
• Defined around patient, not supplier
• Measured over full cycle-of-care
= Value
Source: Institute of Strategy and Competitiveness, Harvard Business School; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
10
Value focus win-win for all stakeholders
Payers & Providers
Transparency on outcomes
Improved quality of care
New decision-support tools
Pay for value delivered
Effective patient choice
• World class outcomes research
• Future clinical research hub
• Unlocking potential in
translational medicine
Patients
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
•
•
•
•
•
Academia
• Best possible outcome...
• ... at minimal cost
Industry
• Unique platform for outcomes
based safety, efficacy and
pricing studies
• New healthcare information
services industries
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
11
Sweden with strong starting point in quality registries
69 quality registries started to date1
>20 registries with >85% patient coverage
Quality registries by start year
(# of registries)
Quality registries by patient coverage, start year
(# of registries)
80
20
69
60
15
22 registries
Start year
of registry
10
9
40
10
4
13
3
5
20
8
2
0
3
0
5
2
0
Not 75-80 80-85 85-90 90-95 95-00 00-05 05-09 Total
known
2
1
>95%
14
2
00-05
2
4
1
1
05-09
1
1
2
2
1
3
1
2
85-95% 75-85% 65-75%
95-00
90-95
3
85-90
4
2
1
<65%
80-85
75-80
Not
known
Patient coverage
1. Only including registries receiving funding from SKL
Source: "National Healthcare Quality Registries in Sweden 2007"; Grant applications; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
12
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
29
10 registries stand out for exceptional level of quality
# of registries
80
Short-list:
69
Cataract
Cataract
60
Gallstone
Gallstone surgery
surgery
46
Pain rehabilitation and
rectal cancer did not pass
selection of > 10,000
patients, but are re-added
due to high report quality
45
40
24
24
30
35
17
0
2
4
12
17
3
1
3
Registries >2 years
Registries
old
measuring patient
Procedure-oriented
outcome
Condition-oriented
All registries
1
Pain
Pain rehabilitation
rehabilitation
Rectal
Rectal cancer
cancer
2
Registries with
>70% coverage
2
Stroke
Stroke
10
4
7
8
2
Intensive
Intensive care
care
Rheumatoid
Rheumatoid arthritis
arthritis
19
20
Hip
Hip arthoplasty
arthoplasty
2
1
1
Swedeheart
Swedeheart
5
Vascular
Vascular surgery
surgery
Registries covering Registries with
>10,000 patients advanced reports
per year
and feedback
Clinic-oriented
Patient-type oriented
Note: See Appendix for detailed registry example
Source: SKL, registry annual reports, registry grant applications to SKL; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
13
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
28
First-class quality registry fulfill six requirements
Strong core team
2
3
Committed
specialists
Valid &
reliable
metrics
Source: BCG analysis
• Atmosphere of cooperation
– Evidence-based discussion
– Mutual respect and team spirit
– Peer pressure in joint efforts
• Evidence-based approach
– Strong foundation in research
– Willingness to measure
• Strong foundation in research
– Internationally tested metrics
– Proven causality
– Possible to benchmark
• In touch with clinical practice
– Practicality filter
• Risk adjustment possibilities
– Collect relevant patient data
Value guided healthcare_Final Documentation_Aug09.ppt
4
Systematic
feedback
5
Easy-to-use
IT interface
6
Stable
financing
• Fast feedback of results
– To allow comparisons over
time for own results
• Learnings linked to feedback
– Learn from others
– Workshops and seminars
– Organized best-practice
sharing
• Easy to enter data
– Only collect what is needed
– Easy-to-use IT interface
– Move towards integration with
EMR systems
• Easy to receive feedback
– Fast feedback of own results
– Decision-support tools
• Access to stable financing
– Backing from institutions
– Clearly delineated budget for
registry admin, maintenance
• Arms-length relationships with
private financiers
– Access to funding without
compromising data integrity
14
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
1
• One team responsible
– Clear process leadership
– Personal dedication
– Sense of ownership
• Strong support from specialists
– Data collection is team effort
• Entrepreneurial "can-do" spirit
– creating winners
~25% of HC-costs already covered by registries
Tax-funded healthcare costs Sweden, 2007
(BSEK)
~2%
150
4%
25%
17
0.3
29
1
106
25
41%
50
8
36
35
25
0
Inpatient1
Outpatient2
Specialist somatic care
Primary care3
Psychiatry4
Total
Cost not captured by current registries
Cost captured by current registries
x% Share captured cost
1. Analysis based on KPP-data 2. Assumptions: Share captured same as for inpatient with adjustment for clinic coverage; for registries covering outpatient care, clinic coverage is same for inpatient
and outpatient 3. Quality registries for diabetes, leg ulcer and heart failure cover primary care; assumptions: cost/patient and visit 2000 SEK, 4 visits/year for diabetes patients; cost/patient and visit
2000 SEK, 52 visits/year for leg ulcer patients; cost/patient and visit 4000 SEK, 4 visits/year for heart failure patients 4. Only existing quality register for psychiatry is eating disorder; assumption
cost/patient and year 200000 SEK; 1355 patient registered in RIKSÄT 2007
Note: Not including cost of pharmaceuticals, dental care, political activities and restructuring activities
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt
15
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
100
25%
Today national quality registries cover 41% of specialized
inpatient cost
MDC
Share of specialized inpatient cost covered by quality registry (%)
00 Ungroupable
01 Nervous system
02 Eye
03 Ear, Nose, Mouth And Throat
04 Respiratory System
05 Circulatory System
06 Digestive System
07 Hepatobiliary System And Pancreas
08 Musculoskeletal System And
Connective Tissue
09 Skin, Subcutaneous Tissue And
Breast
10 Endocrine, Nutritional And Metabolic
System
11 Kidney And Urinary Tract
12 Male Reproductive System
13 Female Reproductive System
14 Pregnancy, Childbirth And
Puerperium
15 Newborn And Other Neonates
16 Blood and Blood Forming Organs and
Immunological Disorders
17 Myeloproliferative DDs (Poorly
Differentiated Neoplasms)
18 Infectious and Parasitic DDs
19 Mental Diseases and Disorders
21 Injuries, Poison And Toxic Effect of
Drugs
22 Burns
23 Factors Influencing Health Status
24 Multiple Significant Trauma
30 Chest problem
90 Post-MDC
100
80
60
40
20
Σ cost captured ≈ 41%
0
0
31
05
08
01
06
62
22
11 07 00 15 17 03 18 23 10 21 30
13 09 12
24
Total specialized inpatient healthcare cost by MDC (BSEK)
99 02
16 19
04
14
Note: Cost data covers specialized inpatient somatic care
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
Cost not captured
Cost currently captured
16
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
(Major Diagnostic Categories)
Unique platform from broad range of personal registries
Personal ID number
Medical outcomes data
• SKL-funded quality
registries
• Other quality registries
– E.g; child cancer
620510-XXXX
Mandatory patient data1
• Socialstyrelsen registries
Drug usage data
• Socialstyrelsen registry
•
•
•
•
•
Epidemiology
Comparative effectiveness
Health economics
Longitudinal studies
...
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Socioeconomic data
• Statistics Sweden
Genetics data
• Biobanks
Other data
Solid patient integrity absolute requirement
1. e.g. medical birth, birth defects, (eg MFR)
Value guided healthcare_Final Documentation_Aug09.ppt
17
Agenda
Starting position
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Shared vision and value captured
Way forward
Appendix
Value guided healthcare_Final Documentation_Aug09.ppt
18
A shared 10 year vision for Swedish healthcare
August 18, 2019
In the past 10 years Sweden has emerged as the leading nation in value based healthcare and personalized medicine.
Today, Swedish physicians and nurses work interactively with outcomes analysis and decision-support tools to deliver
world-class healthcare results for their patients. The Swedish healthcare system displays several unique characteristics:
• Clinical researchers have access to some of the best data sources in the world. Many important clinical breakthroughs
have been made over the last years by teams integrating comprehensive clinical outcomes data with high quality data
from national population and cost registries.
• Swedish patients and their relatives are empowered to make informed care choices based on the quality of care.
Outcomes information services provide transparent performance data for all providers in the country.
• Sweden is the fastest nation in the world in making valuable new drugs available to their population. The Swedish
MPA (LV); the Dental and Pharmaceutical Benefits Agency (TLV) and clinical research competence centers work
closely together to define how to best assess the value of conditionally registered products and efficiently determine
appropriate reimbursement levels.
• Sweden is the pharmaceutical and medical technology industries' country of choice for conducting post-approval
safety, efficacy, and cost-benefit studies. This has been one of the key factors that have enabled a reinvigoration of
the Swedish life-science industry.
In addition to the clinical benefits, focusing on value based healthcare has saved the Swedish taxpayer ~50 BSEK in
reduced direct medical costs. No wonder Sweden is being flocked by researchers from other countries eager to learn how
outcomes and cost measurements can lead to world class research and clinical care.
Value guided healthcare_Final Documentation_Aug09.ppt
19
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Swedish healthcare system envy of world
Swedish experience suggests that vision is realistic
Examples for all stakeholders on following pages
August 18, 2019
In the past 10 years Sweden has emerged as the leading nation in
value based healthcare and personalized medicine. Today, Swedish
physicians and nurses work interactively with outcomes analysis and
decision-support tools to deliver world-class healthcare results for
their patients. The Swedish healthcare system displays several
unique characteristics:
• Clinical researchers have access to some of the best data
sources in the world. Many important clinical breakthroughs
have been made over the last years by teams integrating
comprehensive clinical outcomes data with high quality data
from national population and cost registries.
• Swedish patients and their relatives are empowered to make
informed care choices based on the quality of care. Outcomes
information services provide transparent performance data for
all providers in the country.
• Sweden is the fastest nation in the world in making valuable new
drugs available to their population. The Swedish MPA (LV); the
Dental and Pharmaceutical Benefits Agency (TLV) and clinical
research competence centers work closely together to define
how to best assess the value of conditionally registered products
and efficiently determine appropriate reimbursement levels.
• Sweden is the pharmaceutical and medical technology
industries' country of choice for conducting post-approval safety,
efficacy, and cost-benefit studies. This has been one of the key
factors that have enabled a reinvigoration of the Swedish lifescience industry.
In addition to the clinical benefits, focusing on value based
healthcare has saved the Swedish taxpayer ~50 BSEK in reduced
direct medical costs. No wonder Sweden is being flocked by
researchers from other countries eager to learn how outcomes and
cost measurements can lead to world class research and clinical
care.
Academia
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Swedish healthcare system envy of world
Payers &
Providers
Patient
• Best possible
outcome...
• ... at minimal cost
Industry
Value guided healthcare_Final Documentation_Aug09.ppt
20
Payers &
Providers
Better quality of care without increasing payer cost
Quality versus cost of healthcare in Swedish county councils 2008
Cost/capita
(SEK)
No significant correlation between quality and cost identified
22,000
Gotland
Norrbotten
20,000
Örebro
Gävleborg
Stockholm
Dalarna
Jämtland
Värmland
Skåne
18,000
Uppsala
Västragötaland
Halland
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Västernorrland
Västerbotten
Kalmar
Västmanland
Kronoberg
Jönköping
Sörmland
Östergötland
16,000
40
45
50
55
60
County council quality index
Note: Cost including; primary care, specialized somatic care, specialized psychiatry care, other medical care, political health- and medical care activities, other subsidies (e.g. drugs)
Source: Öpnna jämförelser, Socialstyrelsen 2008;Sjukvårdsdata i fokus 2008; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
21
Example
Reduction of hip
arthroplasty re-operations
from elimination of risk
factors
Reduced amputation
frequency from
systematic selection of
patients for distal bypass
surgery
Reduction in stroke
readmission from
secondary-preventive
activities
Reduction of chronic
disease prevalence and
complications from early
identification of risk
factors
Overall medical cost
savings from adoption of
health information
technology2
Cumulative
throughout period
studied
Medical
category
Source of
saving
Annual
savings11
Surgery
Best-practice sharing
1.5 – 2.0%
Hip-prosthesis registry
Surgery
Prevention
1.0%
Swedvasc
Acute
Prevention
1.5 – 2.0%
Patientregistret /
Socialstyrelsen
Chronic conditions
Prevention
3.0%
Overall
Patient-data analysis
that supports medical
practice
3.0%
Source
Pitney Bowes /
Harvard Business
School
RAND Corporation /
The Economist
1. CAGR 2. EMRs and patient-data analysis tools Source: Hip-protesis annual report 2007; Swedvasc annual report 2007; Harvard Business School case study; The Economist April, 2009;
Öppna jämförelser 2008; BMC Health Serv Res. 2007 7:209. Björkdahl et al.; Riks stroke annual report 2008
Value guided healthcare_Final Documentation_Aug09.ppt
22
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
~1.5% annual savings in HC-costs conservative
estimate of results of outcomes work
Payers &
Providers
Transparency drives best practice sharing (I)
Payers &
Providers
• Care cycle redone
• PCI1 -unit established
• Emergency care expanded
to 24/7 coverage
Ranked #43 of 73 hospitals
• Care aligned with national
treatment guidelines2
• New specialist departments
for specific coronary
conditions started
• Staffing improved
1 year mortality 20%,
Ranked #68 of 73 hospitals
"We felt ourselves that our
care was insufficient. We
pushed for improvements in
cardiac care in Värmland for
many years, but nothing
happened [until the results
became transparent]
-Unit mgr Karlstad Hosp.
Quality index3 raised from 1 to 8,
30-day mortality reduced by 50%
Ranked #22
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Halmstad hospital
Karlstad central hospital
Example: Cardiovascular disease
"[The media] was an alarm
clock. Thanks to the statistics
we received a lot more
resources and could see what
others did that we did not do."
-Hospital mgr Halmstad Hosp.
Quality index raised from 1 to 4
Mortality reduced by 50%
Ranked #45
1. Percutaneous coronary intervention 2. on angiography and PCI 3. Riks-HIA
Source: SVT.se; Aftonbladet 2007-03-08; DN 2009-05-06; Dagens Medicin 2008-08-26; Läkartidningen nr 44 vol. 104, 2007; Värmlands Folkblad 10 Oct 2007
Value guided healthcare_Final Documentation_Aug09.ppt
23
Payers &
Providers
Transparency drives best practice sharing (II)
Example: Birth injury
Starting point
Ryhov hospital ranked #31
of 47 hospitals in 2003
Actions
Staff trained on procedures
Impact
National ranking dramatically
improved:
Cooperation between physicians
and midwifes improved
3
2
2
2005
2006
2007
11
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Strong commitment from staff
31
2003
"We could see that we were behind and felt
that we wanted to do something about it"
"All statistics have been continuously
displayed on a board in the clinic, it has been
important that everyone could follow the
development"
2004
Clinical improvements:
• Sphincter injury
13.7Æ 5.6%
• Perineotomy1 20% Æ 5%
- Unit manager Ryhov Hospital
1. Surgical incision of the perineum during birth
Source: DN 2009-05-06, Dagens Medicin 2008-08-26.
Value guided healthcare_Final Documentation_Aug09.ppt
24
Academia
Quality registries significant source of clinical research
10 short-listed registries important
source of research
~400 publications / year conservative
estimate of future potential
# of publications for short-listed registries
# of publications
50
400
Dissertations
Peer reviewed journals
Dissertations
3
300
18
2
2
21
200
360
44
20
212
36
2
30
10
25
0
0
2006
2004
2005
Short-listed registries
Cataract
Hip arthroplasty
Rheumatoid arthritis
Rectal cancer
Coronary artery disease
Gallstone surgery
Intensive care
Pain rehabilitation
Stroke
Vascular surgery
248
100
13
2003
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
40
30
30
Peer reviewed journals
2007
36
3
Short-listed Including all Potential /
registries1 current quality
year
(current
registries2
registries)
Potential /
year
(adding new
registries)3
1. # of publications for 10 short listed quality registries in 2007 2. Average number of publications per short-listed registry 2007 multiplied by number of registries (59)
3. Adding 31 new quality registries to capture a larger share of total HC-cost
Note: Total number of publications in clinical medicine: 4,000 / year; Total number of dissertations in medicine: 900 / year
Source: Högskoleverket & SCB 2008, KLiniks forskning – ett lyft för sjukvården 2009; registry annual reports, registry grant applications to SKL; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
25
Industry
Great industrial value from late-stage registries
Evolution of quality registry use
Clinical research
Higher quality of care and lower
variance in outcomes through best
practice sharing
Quality of care studies
and best practice sharing
Platform for product
development and
evaluation
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
Reduced outcome variance makes
registry attractive platform for e.g.
product development
• Easier to evaluate effect
Large industry applications potential
• Definition of unmet medical need and
willingness to pay
• Post-marketing safety and efficacy
studies
• Cost-benefit studies
26
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Clinical research feeding into and
benefiting from quality registries
Payers &
Providers
Treatment convergence
facilitates testing of new therapies
Industry
Significantly lower inflammation levels for
rheumatoid arthritis patients
and lower variance in outcomes
Less side-effects (astigmatism) in laser eye
surgery over time and lower variance
Induced astigmatism through laser eye surgery, average and variance
(# of dioptres1)
Average RA CRP value
(%)
45
1,5
1
27
18
0,5
50%
of values
(separator indicates
median for sample)
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
95%
of values
2000
2001
2002
2003
2004
2005
2006
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
0
0
mr
a
9
2007
Average CRP, Sweden (N = 109,270)
Average CRP, Falun3 (N = 5,500)
1. Dipotre = measured as average change of dioptre per clinic based on individual patient data 2. CRP-C = reactive protein level in blood indicating level of inflammation. Lower level of CRP indicate
lower level of inflammation short-term as well as lower risk for inflammation long-term 3. National coverage 56% while Falun coverage is 100% for all types of RA-patients. Since 1997 Falun has
measured and followed-up all its RA-patients on a monthly basis. Data has been used for regional quality work.
Source: Cataract Annual Report 2007; RA Annual Report 2008-09
Value guided healthcare_Final Documentation_Aug09.ppt
27
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
36
Payers &
Providers
Rheumatoid Arthritis registry already reaping full benefits
Academia
Industry
Example of value of late-stage registry
RA registry driving projects in
all registry application areas
Concrete value for all stakeholders –
RA registry capturing full registry value
Payers &
Providers
MSEK
50
~40 MSEK / year
30
Research grant bio banks
Genetic sequencing done abroad
Other research done abroad
20
10
Translational research project
Funding from independent foundations
Sales of clinical data to industry
0
applied
research
funding
Academia
Public funding
direct
registry
funding
Industry
• Attracting 3rd party financing:
~40x public financing
• Opening up new research areas
– Large-scale longitudinal
epidemiological studies
• Industry using registry to validate
new therapies
– eg, TNF-α inhibitors
Total registry funding
Source: Rheumatoid registry, Interview with Lars Klareskog, BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
28
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
40
• Covering significant patient cost:
~1.5 BSEK / year
• Registry interface used in therapy
– Patient tracking own progress
through online application
However, immediate action needed to keep ~5 year advantage
US projected health IT investments
".. objective to support the free choice of
care and encourage patient
involvement...through providing
comparable information on quality and
service for the country's hospitals
20
Electronic health
records
15
5-7 years
10
Health-information
exchanges
5
2011
2013
2015
Patient-data analysis
supporting medical
practice and drug
research
2017
"Quality indicators are helping to
drive improvements in primary and
community care "
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
BUSD
0
2009
European examples
"Through peer-review processes we
have decreased mortality for several
of our clinics"
"We strongly believe in measuring
outcome, and will continue to adjust
and fine tune our current model"
Source: "National Healthcare Quality Registries in Sweden 2007", CSC Healthcare; The Economist, BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
29
Agenda
Starting position
Shared vision and value gained
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Way forward
• Governance model
• Business case
• Roadmap and milestones
Appendix
Value guided healthcare_Final Documentation_Aug09.ppt
30
1
All registries patient and disease focused capturing outcomes over care-cycle across provider
organizations
2
Significant increase in data availability while maintaining highest patient integrity
3
All registries used to identify quality of care best practice and drive continuous improvements
of care. Data use for academic and industrial studies is at the discretion of registry leaders
4
All main stakeholders jointly govern registry infrastructure
5
Registry base funding is secured long-term
6
Better data usage and registry support through shared resources with expertise and tools
7
Registry – industry – regulator (LV and TLV) interfaces are formalized to ensure transparent
and efficient relationships
8
Harmonization of registry IT infrastructure and EMR data entry processes is prioritized
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
8 main principles to reach vision and unlock value
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
31
Governance structure engine for stakeholder value capture
Infrastructure and expertise for evidence-based methodology and processes
Payers & Providers
Outcomes analysis and
reporting
Structured best-practice
sharing
Process improvement
expertise
Academia
Governance structure
other
regs
Steering
Committee
Competence
Centers
Interface for researchers and
financiers
New research topics
In-house analysis expertise
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Quality Registries
Industry
Interface for study design
Sales of registry studies
Information services solution
opportunities
Patients benefit from increased transparency and better
quality of care through all stakeholder activities
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
32
Striking a balance between central scale and local leadership
• National oversight and coordination
Steering Committee
Population
registries
• SKL/Landsting
• SoS
• LV
• UMC1 rep
• Academia rep
• Industry rep
• TLV
• Registry rep
• Patient rep
• Strategy and policy definition
• Basic quality registry funding
• Central audit function
(EpC, SCB etc)
Executive body
(initially PMO role)
• Executive body for assessments,
implementation, follow-up
Providers
Licensing
(LV)
Data use
interface and
services
Reimbursement
(TLV)
Data analysis
services
Facilitate best
practice sharing
Information technology (IT)
• Data use interface and services
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Competence Centers (~6)
Universities
• Data analysis services
• Cooperation with other registries
• Facilitate best practice sharing
• IT infrastructure and support
• Coherence in data, metrics
Industry
• Metrics definition and data capture
• Registry management
Quality Registries
1.University Medical Center
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
33
Proposed funding mechanism balances base funding and
rewards to attractive registries
Private funding for specific
registry study, if approved by
registry owners
Steering committee
Competence Center (CoCe)
Annual direct registry funding2
conditional on participating in
open comparisons through
one CoCe
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Industry
50% of surplus1 allocated by
CoCe to other registries that
can show need for additional
financing
50% of surplus1 from study
to specific registry for
registry-related activities
Fee-for-services
"Development funding"
Funding used for registry
administration, buying
services from CoCe
"Base funding"
Quality registries
1. After reimbursing study specific costs at Competence Center and at registry in question 2. provided by Socialstyrelsen
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
34
Agenda
Starting position
Shared vision and value gained
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Way forward
• Governance model
• Business case
• Roadmap and milestones
Appendix
Value guided healthcare_Final Documentation_Aug09.ppt
35
Business case example: proposed investments with
>10x payback in medical cost only next 10 years
Value based model driving
annual savings of ~1.5% in medical costs...
...equaling >10x
direct medical cost payback
BSEK
~56 BSEK in total savings over 10yrs,
while delivering higher quality of care
300
280
12
9
240
4.75%
7
5
220
4
4.10%
2
200
1
180
0
-5%
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
14
260
Total required investment of ~5 BSEK
over same period
• Registry funding, building competence,
IT, etc.
176
2009
1
185
0
193
201
2010 2011 2012
209
2013
218
2014
226
235
244
2015 2016 2017
254
10.8x multiple of money
coming 10 years
2018
Estimates of societal value at least ~3-5x higher
than direct medical cost savings1
1. Based on benchmarks
Source: SCB, BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
36
Annual costs for establishing governance model
~350-550MSEK
Registry base
funding
Competence centre
seed funding
Required IT- for
complete EMRsolution
Executive body, PMO
and audit function
Annual direct outlay
(MSEK)
Annual direct outlay
(MSEK)
Annual direct outlay
(MSEK)
Annual direct outlay
(MSEK)
500
80
80
150
60
60
400
40
40
200
50
100
0
09 10 11 12 13 14 1518
Annual basic funding per
registry 4 MSEK
Note: All figures in real numbers
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
20
20
0
0
09
10
11
12 13-18
Initial cost related to resources
within competence centre
• 2010: 3 Centers (excl
Uppsala)
• 2011-2012: 5 Centers
0
09
10
11
12
13
Executive body / PMO
• 2009-2013: 30 MSEK
• 2014-18: 20 MSEK
Audit function
• 2010: 5 MSEK
• 2011-2018: 10 MSEK
1418
09 10 11 12 13 14 15 1618
Quality IT investments
complementary to national IT
strategy initiative
Total required investment across
time period: ~600 MSEK
37
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
100
300
Agenda
Starting position
Shared vision and value gained
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Way forward
• Governance model
• Business case
• Roadmap and milestones
Appendix
Value guided healthcare_Final Documentation_Aug09.ppt
38
Four-step approach to realize vision and capture value
2009
2012
2019
Full value capture
Expansion
Ramp-up
• Negotiate governance,
financing
• Establish PMO1
• Set targets, deadlines
• Identify legal obstacles
• Establish shared
capabilities, resources
• Define IT infrastructure
• Drive legal changes
• Push for full registry coverage
• Start new registries
• Reach full data use
infrastructure
August 18, 2019
Swedish healthcare system envy of world
In the past 10 years Sweden has emerged as the leading nation in
value based healthcare and personalized medicine. Today, Swedish
physicians and nurses work interactively with outcomes analysis and
decision-support tools to deliver world-class healthcare results for
their patients. The Swedish healthcare system displays several
unique characteristics:
• Clinical researchers have access to some of the best data
sources in the world. Many important clinical breakthroughs
have been made over the last years by teams integrating
comprehensive clinical outcomes data with high quality data
from national population and cost registries.
• Swedish patients and their relatives are empowered to make
informed care choices based on the quality of care. Outcomes
information services provide transparent performance data for
all providers in the country.
• Sweden is the fastest nation in the world in making valuable new
drugs available to their population. The Swedish MPA (LV); the
Dental and Pharmaceutical Benefits Agency (TLV) and clinical
research competence centers work closely together to define
how to best assess the value of conditionally registered products
and efficiently determine appropriate reimbursement levels.
• Sweden is the pharmaceutical and medical technology
industries' country of choice for conducting post-approval safety,
efficacy, and cost-benefit studies. This has been one of the key
factors that have enabled a reinvigoration of the Swedish lifescience industry.
In addition to the clinical benefits, focusing on value based
healthcare has saved the Swedish taxpayer ~50 BSEK in reduced
direct medical costs. No wonder Sweden is being flocked by
researchers from other countries eager to learn how outcomes and
cost measurements can lead to world class research and clinical
care.
1. Program Management Office overseeing national initiative
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
39
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Registry
initiatives
Functional
initiatives
Strengthen foundation
Need for immediate actions to secure momentum in 2-3 yrs
Strengthen foundation
2010
PMO1
Establish
to
drive initiative
Negotiate governance
setup, key targets
and milestones
2011
2012
Drive key functional initiatives
• Set up Steering Committee
• Secure registry financing
• Push for wider CoCe mandate
• Identify what additional CoCe(s) to start
• Run IT framework project
• Initiate legal change (primary care reporting)
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
2009
Ramp-up phase
Drive key registry initiatives
• Set goals for current registries lacking coverage
• Support start of additional key registries
1. Program Management Office
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
40
Backup
Proposed IT integration process allows for paced
implementation
EMR
database
Quality
registry
EMR
application
Quality
application
• Cumbersome and fault-prone for professionals
• Blocking primary care from full registry
participation
EMR
database
Quality
registry
EMR/Quality
application
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Today's double-entry inefficient and
significant obstacle to full registry coverage
Integrating user interface for EMR11 and quality
registries pragmatic approach for
improvement
• National format specifications defined for select
quality metrics in EMR interface
• Full patient data sent to EMR, select metrics
sent simultaneously to quality registry
Reduced implementation risk when providers can choose
when to move to integrated solution
1. Electronic Medical Record
Source: BCG Analysis
Value guided healthcare_Final Documentation_Aug09.ppt
41
Backup
Implementing registry initiatives would give coverage of 57%
Tax-funded
healthcare costs
(%)
All key chronic illness
visits covered in
primary care
Full coverage in existing
registries Æ 57 % coverage
77%
43%
23%
37%
All key psychiatric
conditions covered
63%
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Additional 6% coverage
from adding key diagnoses
18%
82%
37%
57%
63%
Inpatient
Outpatient
Primary care
Psychiatry
Total
Specialist somatic care
Cost not captured (%)
Cost captured (%)
1. Analysis based on KPP-data 2. Assumptions: Share captured cost same as for inpatient
Note: Not including cost of pharmaceuticals, dental care, political activities and restructuring activities
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; Läkartidningen; peer-review journals; BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt
42
Key milestones to make 10 year shared vision reality
2009
2012
Expansion
2015
Full value capture
2019
Ramp-up phase completed
Well into expansion phase
Realizing full value capture
• ~40% of healthcare cost
covered by registries
• ~55% of healthcare cost
covered by registries
• ~60% of healthcare costs
covered by registries
• All governance, capabilities
components initiated
• All governance, capabilities
components fully resourced
• Full data use ensured through
active Competence Centers
• IT framework established
• EMR interface integration near
completion
• Full EMR interface integration
for quality reporting
• All new registries in start-up
phase
• Target registry coverage
somatic care
• Target registry coverage all care
cycles
• Primary care reporting to patient
registry
Value guided healthcare_Final Documentation_Aug09.ppt
• World-leading commercial
applications
43
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Strengthening
Foundation & Ramp-up
Agenda
Starting position
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Shared vision and value gained
Way forward
Appendix
Value guided healthcare_Final Documentation_Aug09.ppt
44
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Steering Group, Reference Group, Interview list and Meeting participants
45
Steering and reference group members
Role
Carl Bennet
Ordförande i Getinge, Göteborgs Universitet
Anders Ekblom
Vice-President Development AstraZeneca
Maria Anvret
Professor FRCPath, forskningspolitisk talesperson Svenskt Näringsliv, ledamot IVA
Sigbrit Franke
Rådgivare till Umeå & Stockholm Universitet, tidigare Universitetskansler
Claes Ånstrand
Tidigare statssekreterare och landstingsråd
Gunnar Alvan
Tidigare GD Läkemedelsverket
Göran Sandberg
Rektor Umeå Universitet
Kjell Asplund
Tidigare GD Socialstyrelsen
Marie Beckman Suurküla
Sjukhusdirektör Akademiska sjukhuset tillika biträdande landstingsdirektör
Joakim Dillner
Professor, forskare
Anna Hedborg
Tidigare stadsråd och GD
Nina Rehnqvist
Professor, ordförande i SBU
Göran Stiernstedt
Direktör, avd. chef vård och omsorg SKL, tidigare biträdande landstingsdirektör
Ulf Wahlberg
Vice President, industri research relations Ericsson
Gunnar Nemeth
Managing Director and Chief Operating Officer Capio Group
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Reference Group
Steering group
Name
46
>70 interviews – Sweden's starting position (I)
Role
Company
Date
Marie Beckman Suurküla
Hospital Director
Akademiska Sjukhuset Uppsala
May 28
Kristina Pernvi
VP Global Regulatory Op.
Astra Zeneca
May 29
Frederic Sachs
VP Clinical T
Astra Zeneca
June16
Olle Björk
Generaldirektör
Barncancerfonden
Jun 03
Sören Johansson
VP Business development
Elekta
Jun 16
Ulf Wahlberg
Vice President
Ericsson Industry research relations
Jun 11
Gunnar Persson
Register manager
Gall-Riks (gallstone) – Jönköping
May 07
Johan Malmqvist
CEO
Getinge
Jun 12
Per Båtelsson
CEO
Global Health Partners
May 29
Patrik Sobocki
Head of Pricing / Market Access
GSK
Apr 27
Johan Thor
Medical Doctor
Högskolan i Jönköping / KI
Göran Karlström
Register responsible
Intensive care (SIR) – Karlstad
Linus Jönsson
CEO
i3Innovus
Niclas Adler
Managing Director & Dean
Jönköping International BS
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Name
May 04 , Jun 10
May 07
Jun 1
May 07
47
>70 interviews – Sweden's starting position (II)
Role
Company
Date
Göran Henriks
Development director
Jönköpings LL – Qulturum
May 12
Anita Aperia
Professor Pediatrics
Karolinska Institutet
Jun 04
Bo Angelin
Professor Clinical Metabolism
Karolinska Institutet
Jun 04
Anders Ekbom
Professor Epidemiology
Karolinska Institutet
Jun 24
Lars Klareskog
Professor rheumatology
Karolinska Sjukhuset Solna
May 13
Mats Lundström
Registry Manager
Kataraktregistret, EyeNet
May 28
Martin Neovius
Researcher
KI-Centre for Pharmacoepidemology
Jun 1
Richard Bergström
Director-General
LIF
Jun 8
Alicia Lycke
Ombudsman
Läkarförbundet
May 04
Christina Rångemark – Å
Generaldirektör
Läkemedelsverket
May 19
Gunnar Alvan
Former Director General
Läkemedelsverket
Jun 15
Nils Feltelius
Medical Doctor
Läkemedelsverket
May 05
Joakim Dillner
Prof. of Virology Molecular Epid.
Lunds U. Dep.of Medical Microbiology
May 28
Eva Leach
Project leader
Nationella Patientöversikten
May 07
Johan Brun
Medical director
Pfizer
Apr 29
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Name
48
>70 interviews – Sweden's starting position (III)
Role
Company
Date
Lars Påhlman
Register manager
Rectal cancer – Uppsala
May 19
Anna Hedborg
Former Director General
Riksförsäkringsverket
May 28
Sari Wallin
Register coordinator
Riks-Stroke – Norrlands US
May 06
Sten Walther
Registry chairman
SIR
May 25
Nina Rehnquist
Chairman SBU:s nämnd
SBU
May 06
Pär Sundström
IT manager
Sjukvårdsrådgivningen
May 06
Åke Karlsson
Responsible for KPP
SKL
May 19
Göran Stiernstedt
Head of Division
SKL
Aug 11
Roger Molin
Ass.head of Health/Soc care iv
SKL
May 15
Ann Hedberg Balkå
Department Head
SKL
Jun 16
Bodil Klintberg
Registry responsible
SKL, e-health
Jun 5
Karin Johansson
State Secretary
Socialdepartementet
Aug 11
Sara Johansson
Department Secretary
Socialdepartementet
Jun 24
Tobias Nilsson
Political Advisor
Socialdepartementet
Aug 11
Elisabeth White
Research coordinator
Socialdepartementet
Aug 11
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Name
49
>70 interviews – Sweden's starting position (IV)
Role
Company
Date
Henrik Lundström
Topic Expert
Socialdepartementet
Aug 11
Jesper Olsson
Special Advisor
Socialdepartementet
Jun 24
Anders Åberg
Head of Statistics division
Socialstyrelsen
May 18
Karin Nyqvist
Researcher
Socialstyrelsen
Jun 10
Kjell Asplund
Former Director General
Socialstyrelsen
May 29
Mona Heurgren
Director
Socialstyrelsen
May 18
Mona Boström
County Council Director
Stockholms Läns Landsting
June 26
Ulf Stenestrand
Register manager
Swedeheart – Linköping
May 08
Jonas Malmstedt
Register manager
Swedvasc – KI
Apr 28
Peter Fritzell
Register group member
SweSpine (back surgery)
May 11
Maria Fagerqvist
Medical Researcher
TLV
May 07
Thord Redman
Coordinator
TLV
May 07
Peter Lönnroth
Director
Region Västra Götaland
Aug 10
Göran Sandberg
Vice-Chancellor
Umeå University
Bertil Lindahl
Professor
Uppsala Kliniska Forskningscenter (UCR)
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Name
Jun 9
May 26
50
>70 interviews – International benchmarking
Role
Company
Date
Lisa Van Maasakkers
Head Quality mgmt
Schön Kliniken
Apr 30
Roland Brandmeier
Medical Doctor1
Schön Kliniken
May 5
Caroline Powell
CEO
Picker Institute
May 11
Alexander Kirstein
CFO
Universitätsklinikum Eppendorf
May 4
Joe Foley
Director Business Dev.
Cleveland Clinic
Apr 30
Tom Wadsworth
Administrative Director
Cleveland Clinic
Apr 30
Raymond Baxter
SVP Community Benefit
Kaiser Permanente
Jun 12
Alide Chase
SVP Quality and Service
Kaiser Permanente
Jun 12
Jennifer Baron
Research public health
Harvard Business School
Apr 24
Philipp Ostwas
CFO
Klinikum Rechts der Isar
May 4
Gunnar Nemeth
CEO
Capio
May 18
Dr. Mansky
Medical doctor
Helios
May 15
Gene Nelson
Director for quality administration
Dartmouth-Hitchcock
May 21
Dr. David Dreis
Medical director of quality outcome
Virginia Mason
May 11
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Name
Site visits
Schön Kliniken2
Cleveland
Clinic3
May 7
May 14
1. Former head of the department and advisor; 2. One day site visit, incl. discussions with 3 physicians; 3. One day site visit, incl. discussions with quality personnel and 2 physicians
Value guided healthcare_Final Documentation_Aug09.ppt
51
Regeringen
• Karin Johansson, statssekreterare Socialdepartementet
Akademi
• Professor Karin Markides, rektor Chalmers
• VMD. Johan Carlsten, vicerektor Chalmers
• Professor Pam Fredman, rektor Göteborgs universitet
• Professor Olle Larkö, dekanus vid Sahlgrenska akademin
• Professor Harriet Wallberg-Henriksson,
rektor Karolinska Institutet
• Professor Karl Tryggvason, dekanus för forskning på KI
• Professor Peter Gudmunson, rektor KTH
• Professor Mathias Uhlén, KTH
• Professor Mille Millnert, rektor Linköpings universitet
• Professor Björn Gerdle, prodekan Hälsouniversitetet
• Professor Bo Ahren, dekanus medicinska fakulteten
Lunds universitet
• Professor Göran Sandberg, rektor Umeå universitet
(referensgrupp)
• Professor Anders Hallberg, rektor Uppsala universitet
Utländska talare
• Professor Michael E. Porter, Harvard Business School
• Jens Deerberg – Wittram, Chief Operating Officer Schön
Kliniken
Value guided healthcare_Final Documentation_Aug09.ppt
Regioner - landsting
• Sören Olofsson, regiondirektör region Skåne
• Anders Thulin, medicinsk direktör region Skåne
• Hannie Lundgren, forskningschef region Skåne
• Thorbjörn Ekström, FoUU-direktör
Stockholms läns landsting
• Marie Beckman-Suurküla, sjukhusdirektör Akademiska
sjukhuset Uppsala (referensgrupp)
• Jack Lysholm, chef för FoUU-staben
Västerbottens läns landsting
• Peter Lönnroth, biträdande hälso- och sjukvårdsdirektör
Västra Götaland
• Martin Magnusson, utvecklingsdirektör
Östergötlands läns landsting
• Anders Heijl, FoU-samordnare Östergötlands lans landsting
Referensgrupp
• Professor Gunnar Alvan
• Professor Kjell Asplund
• Professor Joakim Dillner
• Anna Hedborg, tidigare statsråd
52
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Gothenburg 18 Aug – Meeting participants (I)
Gothenburg 18 Aug – Meeting participants (II)
Value guided healthcare_Final Documentation_Aug09.ppt
Industri
• Professor Jan Lundberg, Executive Vice President,
Global Discovery Research AstraZeneca
• Anders Ekblom, Executive Vice President,
Global Drug Development AstraZeneca
• Martin Nicklasson, VD och koncernchef Biovitrum
• Gunnar Nemeth, koncernchef Capio (referensgrupp)
• Tomas Puusepp, VD och koncernchef Elekta
• Vice President Ulf Wahlberg, industry research relations
Ericsson (referensgrupp)
• Peter von Ehrenheim, VD GE Healthcare AB
• Per Båtelson, VD och koncernchef Global Health Partner
• Magnus Öhman, VD St Jude Medical AB
• Johan Malmquist, VD och koncernchef Getinge
• Carl Bennet, styrelseordförande och huvudägare Getinge
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Forskningsföreträdare, forskningsrådgivare och
myndighetsföreträdare
• Professor Maria Anvret, forsknings- och innovationschef
Svenskt Näringsliv
• Michaël Berglund, Managing Partner, Michaël Berglund
Executive Search AB
• Professor Håkan Billig, huvudsekreterare
ämnesrådet medicin Vetenskapsrådet
• Professor Sigbrit Franke, tidigare universitetskansler,
rådgivare i forskningsfrågor
• Professor Lars Klareskog, ansvarig för RA-registret
• Docent Bertil Lindahl, ansvarig för kompetenscentrum
(UCR) i Uppsala
• Professor Nina Rehnqvist, ordförande i SBU, Statens
beredning för medicinsk utvärdering samt ordförande i
delegationen för samverkan inom klinisk forskning
(referensgrupp)
• Professor Olle Stendahl, Linköpings universitet
• Christina Rångemark Åkerman, GD Läkemedelsverket
• Claes Ånstrand, tidigare statssekreterare Utbildningsoch kulturdepartementet
Boston Consulting Group (BCG)
• Stefan Larsson, Partner and Managing Director
• Johan Öberg, Partner and Managing Director
• Rasmus Molander, Project Leader
• Peter Svensson Project Leader
53
Value guided healthcare_Final Documentation_Aug09.ppt
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Registry examples
54
GallRiks – Swedish quality registry on gallstone surgery
Registration of biliary surgeries and
endoscopic examinations of bile duct
History
•
Initial discussions about need for a gallstone registry started in
2003, after many meetings to define metrics and anchoring in
the profession the registry started in May 2005
•
Run by the Swedish Surgical Society
Steering group of 7 permanent and 5 deputy members, one
national coordinator
•
Grant from SKL 800 th SEK for 2009
•
•
•
Patient coverage 75% in 2007
Hospital coverage 80% in 2007
8 999 cholecystectomy and 5 128 ERCP1 registered in 2007
•
Information on surgical intervention and postoperative course
for patients
Quality of life is measured before and after surgery
Governance •
Financing
Coverage
From initial discussions to high coverage
register in five years
Initial discussions to
start register in 2003
2003
2004
>90% hospital
coverage
~90% patient
coverage in 2008
Start of register in
2005
2005
2006
2007
2008
2009
Metrics
•
Reporting
process
•
Feedback
process
•
•
•
Web-based reporting through corporation with UCR2
– After operation / examination physicians register in web tool
– Patient surveys reported on paper and registered by local
coordinator on each hospital
– Local coordinator registers follow-up after 30 days, 6-9 months
Annual report; with some health metrics by hospital
Reporting physicians can see own results and hospital average
Reporting hospitals can see their operating physician's results
Key
initiatives
•
Will participate in "Open Comparisons" 2009
1. Endoscopic Retrograde Cholangiopancreatography 2. Uppsala Clinical Research and Registry Center
Source: Interview with registry manager; National Healthcare Quality Registries in Sweden 2007; SKL; annual report; grant application
Value guided healthcare_Final Documentation_Aug09.ppt
55
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Registry example
Swedvasc – Vascular Registry in Sweden
History
•
Started in 1987 as local registry in Southern Sweden, registration
on surveys ended in 2003, registry administrated at UCR since
then, development of new database started in 2006, done by UCR,
Swedvasc 2.0 launched in 2008
•
Run by the Swedish Society for Vascual Surgery
Steering group of 15 members, one coordinator
•
Grant from SKL 900 th SEK for 2009
•
•
•
Patient coverage 95% in 2007
Hospital coverage 100% in 2007
10 166 operations registered in Swedvasc 2007
•
Process metrics
– Reason for intervention, type of surgery and graft, manufacturer
Health metrics
– Complications, function, infection, stroke, mortality
Registration of peripheral vascular surgery
Governance •
Financing
Coverage
Development from small local registry to
nationwide, high coverage registry
Start of VRISS1
registry in 1987
1985
1990
Changed name
to Swedvasc
1994
1995
Registration
on surveys
ended 2003
2000
Swedvasc 2.0
launched in
May 2008
2005
2009
Metrics
•
Reporting
process
•
Feedback
process
•
•
•
Web-based reporting through corporation with UCR2
– Prior to procedure, after procedure, and follow-up after 30 days
and one year
– Reporting normally done by vascular surgeons, at some hospitals
trained nurses take care of it
Annual report; with some health metrics by hospital
On-line analysis of own results and country average on web
Down-loading of data for local analysis
Key
initiatives
•
Launched Swedvasc 2.0, a new version of the registry, in 2008
1. Vascular Registry In Southern Sweden 2. Uppsala Clinical Research and Registry Center
Source: Interview; National Healthcare Quality Registries in Sweden 2007; SKL; annual report; grant application
Value guided healthcare_Final Documentation_Aug09.ppt
56
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Registry example
Riks-Stroke – National Quality Register for Stroke
Registry example
History
•
Started in 1994 on the initiative of Per-Olov Wester, 63% of all
stroke caring units participated from beginning, 100% since
1998, web-based reporting since 2001
•
Steering group with 6 members, working group with 6 members
•
Grant from SKL 2.5 M SEK for 2009
•
•
•
Patient coverage 82% in 2007
Hospital coverage 100% in 2007
24 130 admissions registered in 2007
•
Process metrics
– Care on stoke unit, treatment with pharmaceuticals
Health metrics
– ADL functions before and after stroke, complications, survival
Governance
Financing
Coverage
Registry for quality development in Swedish
stroke treatment
All stroke caring Web-based
Start of register units participate reporting since
in 1994
2001
since 1998
1990
1995
2000
2005
2009
Metrics
•
Reporting
process
•
Feedback
process
•
•
•
Web-based reporting
– Surveys filled in by care takers at occasion of hospitalization,
one person on each hospital responsible for reporting in web
module
– 3 months follow-up of patient experienced data
Annual report; with many health metrics by hospital
On-line analysis of own results and county council average
Participate in "Öppna jämförelser"
Key
initiatives
•
Development of new IT-platform
Source: Interview; National Healthcare Quality Registries in Sweden 2007; SKL; annual report; grant application
Value guided healthcare_Final Documentation_Aug09.ppt
57
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Registration of stroke
Swedish National Hip Arthroplasty Register
Registration of total hip arthroplasty and
partial arthroplasty
History
Governance
•
Registry started in 1979, covered total hip arthroplasty from
start, web-based reporting in 1999, measure patient rapported
variables since 2002, registration of partial arthorplasty started
in 2005
•
Board members, Johan Kärrholm, Göran Garellick, Cecilia
Rogmark and Peter Herberts; steering group with 5 members
Board and steering group is elected after consultation with
Swedish Orthopaedic Association
•
Second oldest registry, went web-based early
Start of register
in 1979,
covered total
hip arthroplasty
1975
1980
1985
Start registration of
Registry
became web- partial arthroplasty
in 2005
based in 1999
1990
1995
2000
2005
2009
Financing
•
•
Grant from SKL 3.0 M SEK for 2009
Support from Västra Götalandregionen
Coverage
•
•
•
Patient coverage 96% in 2007
Hospital coverage 100% in 2007
20 676 registrations in 2007
•
Process metrics
– Implant type, surgical method, operation environment
Health metrics
– Pain, life quality, re-operation, survival after 2, 5 and 10 years
Metrics
•
Reporting
process
Feedback
process
Key
initiatives
•
•
•
•
•
Web-based reporting
– Touch screen linked to registry's website to collect
preoperative patient related metrics
– Surveys are used in follow-up, coordinator report on website
Patient records from re-operations collected and analyzed
Annual report; with many health metrics by hospital
Participate in "Öppna jämförelser"
Start of registry center in the Västra Götaland region, will share
IT-resources, statisticians and office space with NDR and
Onkologiskt centrum
Source: National Healthcare Quality Registries in Sweden 2007; SKL; annual report; grant application
Value guided healthcare_Final Documentation_Aug09.ppt
58
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Registry example
Swedeheart – Coronary heart conditions
Registry example
•
•
Governance
•
•
Financing
•
•
Coverage
Metrics
•
Created by consolidating four registries in 08/09
RIKS-HIA –
acute coronary
care registry
started in 1991
1990
Heart surgery
registry started
1992
SCAAR, national
coronary angiography
registry, started in
1998
1995
2000
Interactive webbased reporting
initiated
2005
2009
SEPHIA, registry for Swedeheart started
secondary prevention as consolidation of
after infarction, started existing coronary
care registries
in 2004
•
•
•
•
Swedeheart created by consolidating acute coronary care
registry, secondary prevention registry, coronary angiography
registry and heart surgery registry in 2008
High and growing coverage in recent years
Steering committee: Ulf Stenestrand, Kristina Hambraeus,
Torbjörn Ivert, Anders Jeppsson, Monica Forslund, Stefan
James
Four working committees covering four areas in registry
Grant from SKL 4.3 MSEK for 2009, of which majority for
competence center tied to registry
Additional financing via grants channeled through UCR on ad
hoc basis
Patient coverage 98% in 2007
Hospital coverage 100% in 2007
62 561 registrations in 2007
Process metrics
– Delay times, diagnostics, acute reperfusion, coronary artery xray, PCI use
Outcome metrics
– Survival rate, symptoms, complications, lifestyle changes,
medication, indicators of following national guidelines
Reporting
process
•
Web-based reporting
– New IT infrastructure under development after consolidation of
old registries
– Attempt to build in decision-support functionality in registry,
unclear legal consequences
Feedback
process
•
•
Annual report; with many health metrics by hospital
Participate in "Öppna jämförelser"
Key
initiatives
•
Several best-practice sharing initiatives organized via UCR
competence center
Contributed heavily to Socialstyrelsen national report on
coronary care published in March 2009
•
Source: National Healthcare Quality Registries in Sweden 2007; SKL; annual report; grant application, Mayo clinic
Value guided healthcare_Final Documentation_Aug09.ppt
59
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Registration of acute coronary care,
secondary prevention, coronary angiography
History
Value guided healthcare_Final Documentation_Aug09.ppt
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Business case support material
60
Business case focuses on medical cost savings only
1 Societal value
•
•
•
•
•
•
Medical cost savings
Reduced compensation for sick-leave
Reduced other compensations
Improved absenteeism
Improved presenteeism
Improved quality of life
Focus for business case
Business case focuses on financial
implications of implementing
recommendations:
• Direct medical cost savings
• Required investments
• Required operating expenses
2 Platform for life-science industry
• Sweden as country of choice for value assessment of
new products eg post-marketing studies and early
launches
• Increased innovativeness in medical system
• New companies & products from translational medicine
• New healthcare information services and decision
support tools industries
Business case shows that medical cost
savings alone unambiguously justify
investment in value guided healthcare
3 Research revenue and publications
• Increased revenues from clinical trials (industry above)
• World class dissertations and articles on drivers of
clinical outcomes
Value guided healthcare_Final Documentation_Aug09.ppt
61
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Three areas of value from outcomes work
High level business case approach
Logic for business case
High level results
Cost reduction from
outcomes work
Medical
saving
Increased cost coverage
by registries
• Multiple of money2 : 10.8x
– Net cash flow ~50 BSEK
Incremental
reduction in
healthcare
cost
Registry base funding
+
Establishing of CoCe1
+
Executive body, PMO,
audit function
Investment
needs
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
x
• 5% of healthcare costs
eliminated by 2018
• NPV3 09-18 ~34 BSEK
– Total NPV ~250 BSEK
• Investment required 0.24% of
annual healthcare spend
– Accumulated spend 3.0% of
2008 healthcare spend
+
IT investment for
complete EMR
1. Competence Centers 2. Multiple of money = Accumulated savings/Accumulated costs 3. Discount rate of 6% assumed
Value guided healthcare_Final Documentation_Aug09.ppt
62
Baseline healthcare cost inflation rate estimated at 4.75%
BCG future estimate
(2008 = 100)
HC cost development
HC cost development
HC cost development
250
160
160
140
140
6.23%
200
150
4.75%
3.50%
120
120
4.78%
100
100
1.5% real growth +
2.0% inflation
80
1995
2000
2005
2006 2008 2010 2012 2014 2016 2018
100
80
2008 2010 2012 2014 2016 2018
1. SKL estimate assumes efficiency improvements from better use of IT-systems, org changes and unidentified other systematic improvements (no reference to specific initiatives/actions is made)
Source: OECD Health data 2008; SKL publication "Kommer vi att ha råd med sjukvården?" 2005
Value guided healthcare_Final Documentation_Aug09.ppt
63
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
SKL future estimate1
(2006 = 100)
Historic growth rate
(1992 = 100)
Outcomes work holds potential to reduce HC cost growth rate
5,0
4,0
3,0
2,0
1,0
0,0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
CAGR (%)
Annual growth in HC cost is reduced
Annual growth
in HC costs
(%)
5.0
w/o
initiative
Expected annual cost reduction
in areas covered by registries (1.5%)
4.5
2,0
1,5
Impact of
proposed plan
1,0
0,5
0,0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
%
100
4.0
with
initiative
Share of healthcare costs
covered by registries
0.0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
50
0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Source: OECD Healthcare Cost 2008, BCG estimates
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
CAGR (%)
Baseline yearly increase
in healthcare costs (4.75%)
64
Backup
Savings to society 3-5x medical cost savings
Medical and societal savings
Comments
BSEK
5x
60
29
24
40
3x
19
14
7
0
0
0
0
1
1
2 4
7
1 2 1 4 2
4
10
5
29
24
10
20
14
7
19
9
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
80
Savings to society from better health /
reduced sickness well above medical costs
• Compensation for sick-leave1
• Other compensations
• Absenteeism
• Presenteeism
12
14
Studies estimating total societal costs put
value at 3–5 x medical costs:
• Obesity 4.4x
• Depression 5.0X
• Overall (Östergötland) 3.0X
• Overall (Healthways in US) 3.7x
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Societal saving max
Societal saving min
Medical cost saving
1. Sick-leave compensation mainly driven by psychological and musculoskeletal diseases
Source: IHE, Östergötland community council healthcare report 2007, Healthways, TLV
Value guided healthcare_Final Documentation_Aug09.ppt
65
Backup
Logic for estimated cost for basic registry funding
Operational activities
Services mainly sourced from
competence centers
Costs for registry operations
IT-supply
Development/updates1
IT costs
Licenses/Software
1,600-1,800 TSEK
Other2
Personnel cost
Metrics definition and
data capture
Provide data analysis services
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Registry management
1,800-2,000 TSEK
Coordinate outcome
improvements across clinics
2-4 Meetings/year
Other costs
Book
400-450 TSEK
Other
1. Including cost for FTEs 2. Follow-up, mobile internet
Note: All figures in real numbers
Source: SIR registry funding application, lönestatistik.se, BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt
Required base funding per registry ~4,000 TSEK
66
Backup
Logic for estimated cost for establishing and strengthening
competence centers
Statistician
Study development
Marketing
Sales support
Personnel cost
Coop. with industry
Coop. with health economics
2010:
2011:
2012:
~6,000 TSEK
~13,000 TSEK
~13,000 TSEK
2010:
2011:
2012:
~850 TSEK
~700 TSEK
~400 TSEK
Legal expertise
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Financial expertise
OH
Training
Specific training
Rent
Office
IT
Other
2010:
2011:
2012:
Required
funding/year:
Note: All figures in real numbers
Source: UCR, BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt
~1,200 TSEK
~1,300 TSEK
~1,300 TSEK
2010: ~25,000 TSEK
2011: ~73,000 TSEK
2012: ~71,000 TSEK
67
Value guided healthcare_Final Documentation_Aug09.ppt
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Logic for increased registry coverage
68
Full patient coverage in existing registries gives 57%
specialized inpatient cost coverage
Full coverage in existing registries increase
cost captured from 41% to 57% (corresponding to 9.6 BSEK)
Key actions to increase
coverage in current registries
Steering Committee communicates
importance of quality registries
• Identify current obstacles and
monitor progress
Share of specialized inpatient cost captured by quality registry (%)
100
80
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Make basic funding contingent
upon joining competence center
60
Underline benefits to registries
from having high patient coverage
• E.g. communicate private-funding
logic
40
Σ cost captured ≈ 57%
20
0
0
31
Total specialized inpatient healthcare cost by MDC (BSEK)
62
Cost not captured
Cost captured if current registries reach full coverage
Cost currently captured
Note: Cost data covers specialized inpatient somatic care
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
69
Setting up new registries increases potential
cost coverage to 63% in specialized inpatient care
Captured cost increases from 57% to 63%
(corresponding to 4.2 BSEK)
Pacemaker
100 operation
Defibrillator operation
Fibrosis
Cirrhosis
Hepatitis
Liver failure
Pancreatitis
Lung emboli
Appendicitis
Ileus
Diverticulitis
Gastrointestinal bleeding
Skin cancer
Define model for new registry
• Develop start-up action plan
• Choose which competence center
registry will be member of
80
Define valid & reliable outcomes
metrics
• Capture full care-chain
• Ensure metrics are anchored in
profession
60
40
Osteoarthritis
Other rheumatic disorders
Chronic pain (palliative care)
Osteoporosis
Skeletal cancer
20
Ensure competence center support
during establishment of registry
Σ cost captured ≈ 63%
0
0
Parkinson
Epilepsy
31
Kidney cancer
Bladder cancer
Urinary tract infection
Burns
62
Total specialized inpatient healthcare cost by MDC (BSEK)
Note: Suggested diseases and disorders can constitute new quality registries, or merge with already existing registries
Source: Interviews; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
Appoint registry management
• Owner and management team
Cost not captured
Cost captured with new registries
Cost captured if current registries reach full coverage
Cost currently captured
70
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Share of specialized
inpatient cost captured
by quality registry (%)
Key actions to establish
new registries
Addition of primary care in quality registries drives full care
cycle coverage
Logic for expansion of quality registries
to also cover primary care
Proposed diagnoses for pilot initiative
Patient has to be in focus rather than HC-function
• Objective to enable tracking throughout care cycle
• Hence, expand registries to cover primary care, not establish
one primary care registry that includes all diseases
Heart failure
COPD
Dementia
Coronary artery disease
Rheumatoid arthritis
Atrial fibrillation
Renal failure
Inflammatory bowel disease
Pilot initiative for 4-5 chronic diagnoses first step towards
including primary care in existing quality registries
• When pilot is up and running, expand to remaining chronic
disorders
Child obesity
Multiple sclerosis
Quality of registry2
Primary care included in registry, high coverage
Primary care included in registry but currently low coverage
1. Based on estimates of primary care cost 2. Based on patient coverage of registry
Source: Interviews, annual reports for quality registries, grant applications to SKL, BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt
Primary care not included in registry
71
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Diabetes forerunner in registry primary care coverage
• 90% of all primary care clinics report into registry (900 clinics)
Pilot
categories
Leg ulcer
Primary care cost1
Registries for chronic diseases initial priority
• Chronic disorders important part of healthcare
– Significant share of total healthcare cost
– Large share of primary care visits
• Limited quality improvement potential for routine diagnoses
e.g., sinus infections, tonsillitis, urinary infections
Diabetes
Asthma
Psychiatry registry development to build on ongoing initiative
SKL
UCR
Funding
36.2MSEK
2008-2010
Support and
expertise
Required actions
Ensure establishment of new competence center is
aligned with proposed Competence Center structure
Detail ongoing initiative
• Plan including concrete goals and milestones
• IT interface1
• Monitoring of initiative to ensure progress according to
plan
Competence Center
Initiate effort to increase patient coverage in existing
registries
• Define action plan
• Identify competences and resources needed to
execute on plan
• Communicate importance and benefits of registries
• Monitor reporting compliance and act if insufficient
RIKSÄT
BipoläR
BUSA
SBR
PsykosR
SÖK
RättspsyK
?
Establish new registries in areas
• Focus on maximizing cost capture
?
1. Specifications on portal: capacity to handle all national quality registries in psychiatry, existing as well as new registries; one single module for patient base information for all users, diagnosis
specific quality registries connected to portal as separate modules
Note :RIKSÄT – Eating disorders, BipoläR - bipolar affective disorder, RUSA - severe adhd, PsykosR – psychosis, SBR – Svenskt Beroende Register, SÖK - Nationellt kvalitetsregister för barn och
ungdomar som konstaterats/misstänks ha blivit utsatta för sexuella övergrepp, RättspsyK – Rättspsykiatriskt kvalitetsregister
Source: SKL; Socialstyrelsen; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
72
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Ongoing initiative to have
9 psychiatry registers in place by 2011
Value guided healthcare_Final Documentation_Aug09.ppt
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Detailed way forward – Roadmaps
73
Actions to get momentum coming 2-3 years and beyond
Program
Management
Office (PMO) /
Exec. body
2010
Establish
PMO
2011
Oversee key implementation projects
• Prepare decision material for steering comm.
• Follow up and provide guidance in key projects
Set up steering
committee
Functional
initiatives
2013
2014
2015-20
Executive body handling permanent
tasks
• Assessment, follow-up
• Decision-support for SC
Initiate legal changes
• primary care, patient data law
Secure full registry
funding
Push for wider
CoCE mandate
Identify new CoCe to start and extend
activities of existing CoCes
Run IT framework
project
Registry
initiatives
2012
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
2009
Implement new integrated IT solution
• Paced implementation according to provider capabilities
Set & meet coverage goals for current registries
Start and get full coverage in additional registries
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
74
Initial roadmap defined through negotiation between
state and counties, anchored with key stakeholders
PMO / Exec. body
1
Financing
Socialdepartementet
Counties
Socialstyrelsen
2
Steering Committee
SKL
SoS
LV
TLV
Provider rep
Patient rep
Academia rep
Industry rep
3
(Modeled on ALF1 framework or similar)
1• Financing mechanism & level
2• Steering Committee setup
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Negotiation and agreement
Program
Management
Office
3• PMO2 mandate & organization
4
4• Initial roadmap
Key functional initiatives
Anchoring3
Licensing
(LV)
Reimbursement
(TLV)
Key registry initiatives
Academia rep
4
Industry rep
1. Avtal om Läkarutbildning och Forskning – Negotiated agreements between the state and select counties regarding co-financing for specialised medical education and research. 2. Program
Management Office. 3. Potentially involving Letters of Intent from key stakeholders. 4. Potentially ínvolving Vetenskapsrådet. Source: Interviews with Claes Ånstrand June 2009, BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
75
Functional initiatives
High level roadmap to develop the required functional areas
2009
2010
Estab. PMO1
Governance
2011
2012
PMO – monitoring implementation process
Est. Steering Committee
2013
2014
2015-20
Exec. body – permanent SC support tasks
Nat. framework for stakeholder partnering
Basic funding logic Establish additional CoCe
Strengthening of existing CoCe
Resource/
competence
development
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Assess resource requirements
Map competence and registry gap
Appoint new reg. team, strengthen exist
Gradual training / recruiting
Def. framework
Information
technology
(IT)
Adapt providers to integrated solution according to timeplan for compliance
Develop decision-support tools for integrated solutions
Require primary care to report according to DRG
Legal
Revise law on patient data to allow real-time feedback
1. Program Management Office
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
76
Functional initiatives
Detailed roadmap for establishing proposed
governance model
PMO established
SC starting to get
in place
SC established
Funding model in
place
CoCe operating
according to
defined model
2010
2011
2012
2009
Establish
Exec.
body/PMO1
1.Program Management Office
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
2013
Exec. body/PMO – monitoring implementation process
• Frequent evaluation of progress relative to time plan
• Overall prioritization
Establish Steering
Committee
• Appoint members,
define plan / vision
Governance
National framew.
for cond.
licensing in place
6 CoCes
established
PMO phased out
2014
2015-20
Executive body with permanent
Steering Committee support
function
Establish additional CoCe
• Support and guidance from
existing CoCe
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Key
milestones
Set up framework
for conditional
licensing &
reimbursement
• Test framework
w. pilot
Strengthening of existing CoCe
• Create coherent vision
• Set up objectives, time plans and resource needs
Determine process for
making outcome data public
to patients
Integrate regional cancer registries
into new national CoCe-model
Ensure full and
stable basic
registry funding
Determine BP sharing
process
77
Functional initiatives
Detailed roadmap for resource and competence development
Key
milestones
All required
registries started
2009
2010
Assessment
of resource
requirements
for CoCe
2011
2012
New CoCe /
governance model
fully in place
2013
2014
2015-20
Identify areas of registries
needed, appoint owner
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Resource/
competence
development
Appoint team for new registries;
ensure competence and resource
distribution
For existing registries; evaluate
and strengthen resources and
competence needed
Mapping of
competence
need vs.
availability
Define approach
for adjusting
resource pool
Gradually educate / recruit new competences e.g.
legal, finance, marketing and sales support
Build statistical and epidemiological expertise within
CoCe
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
78
Functional initiatives
Detailed roadmap for IT and Legal
IT-requirements
for VBHC-model
defined
Key
milestones
2009
2010
Framework and
timeplan defined
Integrated EMR
solution for all
registries
All potential legal
obstacles solved
2011
2012
2013
2014
2015-20
Define framework,
timeplan for
integrated IT
solution
Information
Technology
(IT)
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Adapt providers to integrated solution according to paced timeplan for
compliance
Develop decision-support tools for integrated solutions in
collaboration with registry owners
Change law to require primary care reporting
into SoS patient registries
Legal
Revise Law on patient data to enable e.g. individual
feedback from quality registries and cross-referencing
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
79
Registry initiatives
High level roadmap to increase registry quality
2009
Increase
coverage in
current
registries
2010
2011
2012
2013
2014
2015-20
Launch initiative
Define action plan
Monitor progress
Arrange BP-sharing meetings
Add new
registries
App. owner
Build registry
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Assess. new reg.
Monitor progress
Support process
Integrate cancer registries
Develop action plan
Primary
care
Assign pilot
"owner"
Expand registry
Develop evaluation
process
Ensure full coverage
Evaluation of pilot and give feedback
Develop IT interface solution
Expand pilot to all relevant areas in PC
Organize best practice sharing for registries
Launch initiative
Psychiatry
Build registry
Define action plan existing & new reg.
Ensure full coverage existing and new reg.
Organize best practice sharing for registries
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
80
Detailed roadmap for increasing coverage in current
registries
Defined action
plan for coverage
increase
Key
milestones
2009
2010
2011
Registry initiatives
Full patient coverage
in current registries,
i.e. inpatient &
outpatient
2012
2013
2014
2015-20
Launch
coverage
initiative
Increase
coverage in
current
registries
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Define action plan; id
gaps & capabilities,
resource needed
Ensure full coverage for inpatient
• Communicate importance and
benefits of registries
• Ensure compliance from clinics
Specific initiative to ensure full
outpatient coverage
• Identify white-space
• Communicate importance of
participation
• Ensure compliance from
clinics
Organize best-practice sharing meetings
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
81
Registry initiatives
Detailed roadmap for establishing new quality registries
>95% patient
coverage for all
registries, i.e.
inpatient & outpatient
All new quality
registries launched
Cancer registries
Key
milestones
2009
2010
2011
2012
2013
2014
2015-20
Assess. of new reg
needed. App. owners
Build registry according to identified
best-practice model
• Ensure full coverage
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
New quality
registries
Develop individual
action plan for new
registry
• Identify
resources and
competence
needed
• Identify metrics
• Decide on
CoCemembership
Organize BP sharing
Integrate regional and national
cancer registries for each
diagnoses
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
82
Detailed roadmap for including primary care in quality
registries
Pilot in PC with
3-4 chronic
disorders
initiated
2009
2010
Assess. of
pilot
registries,
appoint
owner
2011
2012
Expand registries
to primary care
• Communicate
importance
and benefits
of participating
Develop plan for
expansion of
current registry to
primary care
• Resources &
competences
• Metrics
Develop process for
evaluation of pilot
Primary care
2013
2014
All chronic
conditions treated
in PC covered in
quality registries
2015-20
Ensure full
coverage in
pilot
• Ensure
compliance
from clinics
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Key
milestones
Full patient
coverage
selected
disorders in pilot
Registry initiatives
Evaluate pilot and give feedback
• To pilot registries
• To expansion registries
Organize BP sharing
Identification
of expansion
registries,
appoint
owner
Expand pilot to all relevant chronic disorder in
primary care
Develop common IT-interface for primary care
• Same for all registries
Develop and implement common classification system
for diagnoses and treatments in all primary care clinics
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
83
Detailed roadmap for establishing psychiatry quality
registries
Full patient
coverage for all
registries
Full patient
coverage existing
registries
Key
milestones
2009
2010
2011
2012
Registry initiatives
2013
2014
2015-20
Set detailed goals &
milestones for
expanded initiative
Psychiatry
Identification
of expansion
registries,
appoint
owner
Copyright © 2009 by The Boston Consulting Group, AB. All rights reserved.
Define action plan for full
coverage existing registries
• Identify competence, resource
needed
Ensure full cov. for existing registries
• Communicate importance and benefits
of registries
• Ensure compliance from clinics
Develop action
plan for new reg.
• Resources and
competence
needed
• Identify metrics
Build registry
according to
identified bestpractice model
Ensure full coverage
• Communicate
importance and
benefits of registries
• Ensure compliance
Alignment of KPV1 structure
with new CoCe model
Organize best practice sharing
1. Kvalitet i Psykiatrisk Vård – Recently established CoCe for psychiatry. Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt
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